Neck-shoulder pain (NSP) is a highly prevalent musculoskeletal disorder with unclear causes, and effective prevention and treatment require a further understanding of the underlying mechanisms. Aberrant autonomic nervous system (ANS) regulation is a hypothesized causal element in the development and maintenance of chronic muscle pain. The overall aim of this thesis was to investigate possible differences in ANS regulation between chronic NSP and healthy control (CON) groups using both laboratory assessment and ambulatory monitoring in daily life. Four papers are included in this thesis, based on data from three groups with chronic NSP. Autonomic responses to laboratory stressors were assessed using heart rate variability (HRV), blood pressure, trapezius muscle activity and blood flow measurements (Study І) in NSP and CON. Long-term ambulatory monitoring of HRV, physical activity and perceived symptoms were assessed in Studies ІІ and IV to investigate group differences in real-life conditions. Finally, the effects of a ten-week intervention (using individually adjusted HRV biofeedback) to reinstating ANS balance in subjects with chronic NSP were evaluated using self-reported symptoms and health ratings, as well as autonomic regulation testing (i.e., evaluating HRV at rest and in response to stress) (Study ІІІ). The main findings from the four studies demonstrated aberrant ANS regulation in the NSP group compared to CON, which was predominantly characterized by diminished parasympathetic cardiac activity during rest and sleep, and altered sympathetic reactivity to laboratory stressors (Studies І, ІІ and IV). Different patterns in physical activity were observed between the NSP and CON groups, with reduced physical activity during leisure time in the NSP group (Studies ІІ and IV). Physical activity was found to be positively associated with HRV. Positive effects of HRV-biofeedback were found on perceived health, including social function, vitality and bodily pain, and improved HRV (Study ІІІ). In conclusion, imbalanced ANS regulation was demonstrated among persons with chronic NSP at both the systemic and local levels. Diminished parasympathetic activity in NSP was modulated by lower levels of physical activity in leisure time. Interventions targeting ANS functions might benefit persons with chronic NSP.

Daily Physical Activity (DPA) is one component of Ontario’s Healthy Schools strategy. This case study of two schools in geographically and culturally diverse contexts explores DPA implementation according to the focus areas of the Ministry of Education. The conceptual framework of Clune (1990) was employed to explore implementation according to three perspectives, revealing disconnects between the policy mandate and educational contexts, as well as potential improvements to the current policy. It was found that time constraints are the most prominent barrier to DPA implementation, and that the primary focus of DPA for educators is often provision, but not quality, of daily physical activities. It was also found that teachers’ perceptions of policy importance are a stronger predictor of implementation than a supportive school administration, given there is no conflict with other school policies. Recommendations for policy revisions are provided based on the findings.

Daily Physical Activity (DPA) is one component of Ontario’s Healthy Schools strategy. This case study of two schools in geographically and culturally diverse contexts explores DPA implementation according to the focus areas of the Ministry of Education. The conceptual framework of Clune (1990) was employed to explore implementation according to three perspectives, revealing disconnects between the policy mandate and educational contexts, as well as potential improvements to the current policy. It was found that time constraints are the most prominent barrier to DPA implementation, and that the primary focus of DPA for educators is often provision, but not quality, of daily physical activities. It was also found that teachers’ perceptions of policy importance are a stronger predictor of implementation than a supportive school administration, given there is no conflict with other school policies. Recommendations for policy revisions are provided based on the findings.

Bakgrund: Att barn blir allt mer stillasittande är alarmerande eftersom levnadsvanor och livsstil under barndomen har betydelse för uppkomsten av ohälsa i vuxenlivet. Skolan är en viktig arena i främjandet av barns hälsa och dagliga fysiska aktivitet. Enligt läroplanens uppdrag är det lärares och rektorers uppgift att sträva efter att erbjuda alla elever daglig fysisk aktivitet inom ramen för hela skoldagen. Syfte: Att undersöka lärares och rektorers upplevelser av att främja elevers dagliga fysiska aktivitet utifrån det stöd som ges till skolan och de faktorer som påverkar skolans förutsättningar. Metod: Data samlades in genom tio semistrukturerade intervjuer på fem skolor inom tre på förhand utvalda kommuner. Insamlat data analyserades genom kvalitativ innehållsanalys med fokus på det manifesta i innehållet. Resultat: Huvudresultatet visade att respondenterna upplevde att arbetet med att främja daglig fysisk aktivitet varierade beroende på hur detta arbete var prioriterat i verksamheten. Stöd från rektor, kommun och föräldrar ansågs vara viktigt för att fysisk aktivitet ska prioriteras. Påverkande faktorer upplevdes vara kunskapskravet, synen på fysisk aktivitet, skolgårdens karaktär samt tillgången till stimulerande miljöer. Därtill upplevdes att elevernas minskade intresse för fysisk aktivitet och det ökade intresset för elektronisk underhållning försvårade arbetet. Slutsats: För att öka insatserna för att främja elevers dagliga fysiska aktivitet bör medvetenheten om läroplanens uppdrag om daglig fysisk aktivitet öka. Det krävs även en förändrad syn på fysisk aktivitet för att skolor ska ges större möjligheter att arbeta med detta. Därtill behöver involverade aktörer ge mer stöd till skolorna för att uppdraget ska prioriteras i verksamheten. / Background: The increasing prevalence of sedentary behavior among children is alarming since unhealthy living habits and lifestyle during childhood is a risk factor for ill health in adulthood. Schools play an important role when promoting children’s health and daily physical activity. According to the curriculum, teachers and principals are expected to promote daily physical activity to all students during the school day. Purpose: To examine teachers' and principals' experiences in promoting daily physical activity to students based on the support given to the school and the resources available. Method: Data was collected by ten semi-structured interviews conducted in five schools within three municipalities. Data was analyzed by using qualitative content analysis with a focus on the manifest content. Results: Respondents experienced that efforts varied depending on how physical activity was prioritized by the school. Support from the principal, the municipality and the parents was considered important in order to increase these efforts. Factors that influenced the delivery included the pressure to meet the curricular requirements for other subjects, the views on physical activity, the school yards’ characteristics as well as the access to stimulating environments. The decreased interest in physical activity and the increased interest in electronic entertainment was also seen as a challenge. Conclusion: The awareness of the existing curriculum on daily physical activity should increase in order to put more effort on promoting daily physical activity to students. For this to be possible, the view on physical activity has to change. Increased support from stakeholders is also needed in order to prioritize daily physical activity in schools.

Rising obesity rates and low physical activity levels among children and youth are a global concern due to links to adverse health outcomes, poor quality of life, and an increased burden on the health care system. One response to the problem has been the implementation of school-based physical activity and nutrition policies. For example, the Ontario Ministry of Education’s Daily Physical Activity (DPA) Policy mandates that all elementary school students receive at least 20 minutes of physical activity per day. This exploratory research sought to understand the local-level factors shaping implementation of DPA, from the perspective of elementary school teachers and principals. Qualitative in-depth interviews were conducted with Ontario grade 1-8 teachers (n=14) and elementary school principals (n=5) regarding DPA implementation, facilitators, barriers, perceived outcomes, and suggestions for change. Interviews were audio recorded (with permission) and transcribed verbatim for subsequent thematic analysis using NVivo. Although all but two participants indicated they had implemented DPA, the majority reported that students were not meeting the requirement daily. Findings were organized using the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. Implementation facilitators were focused within the microenvironment (i.e., classrooms and schools), while barriers were identified within both the micro- and macroenvironments (i.e., classrooms, schools, school boards, and the Ministry of Education). Both teachers and principals considered DPA a lower priority than other subjects, partly because of limited monitoring of implementation within schools and school boards. Participants discussed student benefits resulting from DPA; however, student fitness was not identified as a positive outcome- in fact, some questioned whether the policy is improving student physical activity levels. The results suggest the status of DPA results from a failure of implementation rather than a failure of concept. Participants believed increasing student physical activity levels was important; however, they argued that factors within the classroom, school, school board, and Ministry of Education limit the feasibility of delivering DPA. This thesis contributes to the limited literature regarding the evaluation of DPA implementation and outcomes by exploring the perspectives of teachers and principals implementing the policy. Substantive, methodological, and theoretical contributions to the school-based physical activity literature are discussed, followed by policy implications and directions for future research.

Rising obesity rates and low physical activity levels among children and youth are a global concern due to links to adverse health outcomes, poor quality of life, and an increased burden on the health care system. One response to the problem has been the implementation of school-based physical activity and nutrition policies. For example, the Ontario Ministry of Education’s Daily Physical Activity (DPA) Policy mandates that all elementary school students receive at least 20 minutes of physical activity per day. This exploratory research sought to understand the local-level factors shaping implementation of DPA, from the perspective of elementary school teachers and principals. Qualitative in-depth interviews were conducted with Ontario grade 1-8 teachers (n=14) and elementary school principals (n=5) regarding DPA implementation, facilitators, barriers, perceived outcomes, and suggestions for change. Interviews were audio recorded (with permission) and transcribed verbatim for subsequent thematic analysis using NVivo. Although all but two participants indicated they had implemented DPA, the majority reported that students were not meeting the requirement daily. Findings were organized using the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. Implementation facilitators were focused within the microenvironment (i.e., classrooms and schools), while barriers were identified within both the micro- and macroenvironments (i.e., classrooms, schools, school boards, and the Ministry of Education). Both teachers and principals considered DPA a lower priority than other subjects, partly because of limited monitoring of implementation within schools and school boards. Participants discussed student benefits resulting from DPA; however, student fitness was not identified as a positive outcome- in fact, some questioned whether the policy is improving student physical activity levels. The results suggest the status of DPA results from a failure of implementation rather than a failure of concept. Participants believed increasing student physical activity levels was important; however, they argued that factors within the classroom, school, school board, and Ministry of Education limit the feasibility of delivering DPA. This thesis contributes to the limited literature regarding the evaluation of DPA implementation and outcomes by exploring the perspectives of teachers and principals implementing the policy. Substantive, methodological, and theoretical contributions to the school-based physical activity literature are discussed, followed by policy implications and directions for future research.